Applied Nursing Research 45 (2019) 17–22

Contents lists available at ScienceDirect

Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Original article

The suitability of motivational interviewing versus cognitive behavioural T

interventions on improving self-care in patients with heart failure: A
literature review and discussion paper
Han Shi Jocelyn Chew (BSN, RN, PhD Candidate) , Ho Yu Cheng (RN, PgD, PhD) (Assistant
⁎

Professor), Sek Ying Chair (RN, MBA, PhD) (Director and Professor)
Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong

ARTICLE INFO ABSTRACT

Keywords: Background: Chronic heart failure remains a major public health concern due to its high prevalence and disease
Cognitive burden. Although self-care has been advocated as the sustainable solution, it remains inadequate. Recent studies
Heart failure have shown the potential of integrating structured counselling elements into traditional educational programs to
Motivational interviewing enhance self-care but the optimal counselling method remains unclear.
Self-care
Aim: To compare the applicability of cognitive behavioural interventions and motivational interviewing on
Self-management
improving self-care behaviours in patients with chronic heart failure.
Method: A systematic three-step search strategy was used to identify studies that incorporated cognitive beha-
vioural interventions and/or motivational interviewing to improve heart failure self-care. Quantitative and
qualitative trial studies that met the inclusion criteria were appraised using the Joanna Brigg's Institute criteria.
Results: Motivational interviewing showed higher potential in improving HF self-care behaviours, but sustain-
ability remains unclear. Cognitive behavioural interventions only showed effectiveness when applied to patients
with comorbid depressive symptoms. Statistically significant results were only elucidated upon statistical ad-
justments and examination of behaviours individually. Potential effective components of CBI include setting up
environmental reminders, addressing misconceptions and skills-training while that of MI was the communica-
tion style.
Conclusion: MI and CBI could be used synergistically by extracting their key effective components to strengthen
the intention-behaviour link in improving HF self-care behaviours. MI could be used to enhance the intention to
change by evoking ambivalence and change talk. CBI could be used to enhance problem-solving skills and set
environmental reminders to strengthen the translation of intention to behaviour.

1. Background care to reduce symptoms due to cardiac decompensation, thereby re-

Globally, chronic heart failure (HF) affects approximately 1–2% of
adults in developed countries, predicts a 50% 5-year survival rate and
costs approximately US$108 billion each year (Cook, Cole, Asaria,
Jabbour, & Francis, 2014; Tung et al., 2016). While HF mortality rates
have improved by 33% and 24% in men and women respectively,
readmission rates remain high with an estimated prevalence of 25% in
the United States and 3% to 15% in Asia (Feltner et al., 2014; Reyes
et al., 2016). As the risk of HF increases with age, a global ageing po-
pulation is bound to increase the healthcare burden for beds, man-
power, subsidies and insurance coverage (Cook et al., 2014; Tung et al.,
2016). Various guidelines have since promoted the adoption of HF self-
ducing the risk of rehospitalisation by about 35% but HF-related
readmissions remain high due to poor self-care (Ziaein & Fonarow,
2016; Moser et al., 2012).
1.1. HF self-care
HF self-care refers to a set of protective behaviours including
medication adherence, dietary and fluid restrictions, physical activity,
symptom monitoring, flu vaccination and symptom management
(Riegel, Lee, Dickson, & Carlson, 2009). Although studies have showed
that improving knowledge (Yehle & Plake, 2010) and skills (Dickson,
Melkus, Katz, et al., 2014) are effective in improving self-care

⁎
Corresponding author at: 601, Esther Lee Building, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong.
E-mail address: jocelyn.chew.hs@link.cuhk.edu.hk (H.S.J. Chew).

https://doi.org/10.1016/j.apnr.2018.11.006
Received 7 May 2018; Received in revised form 2 November 2018; Accepted 5 November 2018
0897-1897/ © 2018 Elsevier Inc. All rights reserved.
H.S.J. Chew et al. Applied Nursing Research 45 (2019) 17–22

Articles identified through database searching (n=1613):

CINAHL (n=165) ScienceDirect(n=110) Scopus (n=580)
MEDLINE (n=267) PsychINFO (n=115) ProQuest (n=6)
PubMed( n=131) Cochrane Library (n=239)

Duplicate articles removed (n=907)

Articles screened for abstract and title (n=706)

Nature of articles excluded (n=642):

Systematic review (n=64)
Other reviews (n=66)
Study protocols (n=41)
Perceptions of healthcare professionals (n=24)
Perceptions on living with CHF (n=52)
Scientific statements, guidelines, current status (n=27)
Influencing factors of self-care (n=114)
Not on self-care behaviours (n=94)
Psychometric/assessment tool development and/or
validation (n=13)
Non-CHF (n=62)
Paediatric (n=8)
Non-english (n=11)
Grey literature (n=66)

Full-text articles assessed for eligibility (n=64)

Articles excluded (n=52)

Does not contain structured counseling (n=49)
Cognitive training (n=2)
Process evaluation of another RCT (n=1)

Articles retrieved from bibliography (n=0)

Total articles assessed according to JBI critical appraisal of methodological

quality forms (all met requirement of 60%) and included in review (n=12)

Fig. 1. Flow diagram of search process and outcome.

behaviours, others have shown that it is insufficient and the sustain-
ability of post-intervention effects are rarely reported (Barnason,
Zimmerman, & Young, 2012; Creber, Patey, Lee, et al., 2016). This
suggests that initiating and sustaining health behaviour changes may
not be as simple as imparting knowledge or skills.
According to systematic reviews, other influencing factors of self-
care include: perceived heath beliefs (e.g. severity of illness and self-
care effectiveness) (Oosterom-Calo, Van Ballegooijen, Terwee, et al.,
2012); self-efficacy (confidence) (Chen et al., 2014; Peters-Klimm,
Freund, Kunz, et al., 2013); motivation (Klompstra, Jaarsma, &
Strömberg, 2015); and perceived control (empowerment) (Crundall-
Goode, Goode, & Clark, 2016; Shearer, Fleury, Ward, & O'Brien, 2012).
Qualitative findings have also reported patients' desire to feel normal
but having to perform daily weighing, diet restriction and symptom
monitoring are considered abnormal when compared to their lifestyle
before being diagnosed with HF (Chew & Lopez, 2017; Mahoney,
2001). These factors are psychological in nature and could be addressed
by using counselling methods. Therefore, a literature search was con-
ducted to find out the common counselling methods used to improve
HF self-care where cognitive behavioural interventions (CBI) and mo-
tivational interviewing (MI) were found to be most popularly used.
1.2. CBI versus MI: theoretical underpinning
Cognitive behavioural interventions (CBI) are mostly oper-
ationalized based on cognitive behaviour therapy (CBT), a structured
goal-oriented process that assumes that problematic behaviours and
emotions are caused by cognitive maladaptation (Hyland & Boduszek,
2012). Key components are cognitive restructuring (CR), a process of
recognizing and resolving irrational thoughts through relearning ra-
tional interpretations of certain events (Lundgren, Andersson, &
Johansson, 2015) and behaviour modification (BM), adapting beha-
vioural responses towards specific needs and events. CBT often requires
eight to twelve sessions, lasting for 60–90 mins per session (Bryant,
Moulds, Guthrie, et al., 2008).
Motivational interviewing (MI) refers to a goal-orientated process
that assumes ambivalence as a normal part of the motivation to change
(Miller & Rollnick, 2012). It is based on the spirit of collaboration;
evocation and autonomy and the principles of expressing empathy;
enhancing self-efficacy; rolling with resistance and evoking dis-
crepancies (Miller & Rollnick, 2004). These guide the demonstration of
four tenet skills: asking open-ended questions; providing affirmations;
reflective listening and summaries (Martins & McNeil, 2009). Effec-
tiveness of MI is best operationalized by “change talk”, which are
statements that indicate the intention, motivation or commitment to

18
H.S.J. Chew et al.
change (Apodaca & Longabaugh, 2009). MI is often used as a brief
therapy or prelude of one to four average 60 min' sessions (Lundahl,
Moleni, Burke, et al., 2013).
CBI has been used to treat depression (Karyotaki et al., 2017), stress
and anxiety (Olatunji et al., 2014), eating disorders (Fairburn et al.,
2015) and pain (Cherkin et al., 2016). MI has been used to manage
substance abuse (Satre et al., 2016; Spohr, Taxman, Rodriguez, &
Walters, 2016), promote health service utilization such as mental
health services (Syzdek, Green, Lindgren, & Addis, 2016) and manage
chronic diseases such as diabetes and heart failure (Creber et al., 2016;
Pladevall, Divine, Wells, Resnicow, & Williams, 2015). Studies that
compared the effectiveness of both methods separately and combined
but were mostly in patients with mental health issues such as schizo-
phrenia, alcohol dependence and depression (Barrowclough et al.,
2001; Riper et al., 2014). To the authors' best knowledge, randomized
controlled trials or papers comparing the effectiveness of both methods
on improving self-care in patients with HF could not be found. There-
fore, this paper aims to discuss the suitability of CBI and MI in im-
proving self-care in patients with HF, which could inform future re-
search in terms of intervention developments and understanding the
underlying mechanism of behaviour change.
2. Method
A systematic three-step search strategy was used to identify research
articles across eight electronic databases published between 2006 and
2016 that tested the effectiveness of CBI and MI on improving HF self-
care (Aromataris & Riitano, 2014). The search generated 1613 articles:
CINAHL (n = 165); MEDLINE (n = 267); PubMed (n = 131); Cochrane
Library (n = 239); ScienceDirect (n = 110); PsycINFO (n = 115);
Scopus (n = 580) ProQuest (n = 6). 907 duplicate articles were ex-
cluded, 642 articles were excluded following abstract and title screen,
resulting in the assessment of 64 full-text articles where 52 were further
excluded with reasons. Methodological quality appraisal was conducted
using the Joanna Briggs Institute's (JBI) critical appraisal form (The
Joanna Briggs Institute, 2016). Articles were included if they scored
more than > 60% according to the aforementioned JBI criteria, re-
sulting in twelve articles included in this literature review (Fig. 1). Data
was first extracted using a data extraction form and organized into a
table with headings: authors; theoretical framework; study design;
counselling method; approach; sample characteristics, inclusion cri-
teria, exclusion criteria, remarks and attrition. Data was further ab-
stracted and synthesized.
3. Results
Twelve studies were included with nine randomized controlled
trials (RCTs) (Agren, Evangelista, Hjelm, & Strömberg, 2012; Cockayne,
Pattenden, Worthy, Richardson, & Lewin, 2014; Creber et al., 2016;
Freedland, Carney, Rich, Steinmeyer, & Rubin, 2015; Otsu & Moriyama,
2011; Paradis, Cossette, Frasure-Smith, et al., 2010; Powell, Calvin,
Richardson, et al., 2010; Smeulders, van Haastregt, Ambergen, et al.,
2009, 2010), one quasi-experimental trial (McCarthy, Dickson, Katz, &
Chyun, 2016) and two mixed-method studies (Riegel et al., 2006;
Riegel, Dickson, Garcia, Masterson Creber, & Streur, 2017). The studies
represented 1930 participants with mean ages ranging from 53.40 to
75.76 years, predominantly included males and were classified under
New York Heart Association functional class (NYHAFC) II. Six studies
employed CBI and six employed MI.
Common self-care behaviours measured were daily weighing,
medication adherence, sodium restriction, physical exercise, symptom
monitoring and management. Fewer studies measured diet, cigarette
smoking and alcohol consumption as an outcome. Five studies mea-
sured self-care using the Self-care in HF Index (SCHFI), which has three
subscales – maintenance, management, and confidence; three studies
employed the European Heart Failure Self-Care Behaviour Scale; and
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Applied Nursing Research 45 (2019) 17–22
the rest used other self-report instruments. It is noteworthy all six
studies that used SCHFI measured self-care behaviours using the SCHFI
maintenance subscale besides the whole index as recommended by the
original authors, considering that not all participants would have ex-
perienced events that require management.
3.1. CBI versus MI: effectiveness on improving self-care behaviours
Among the CBI studies, only Smeulders et al. (2009, 2010) reported
significant improvements in physical activity (p = 0.006) and overall
self-care scores upon 6 weeks follow-up (p = 0.008) in participants who
received a cognitive-behavioural program compared to those who re-
ceived usual care comprising regular follow-ups. Similarly, Powell et al.
(2010) reported greater adherence to sodium restriction in the CBI self-
management group (28%) (time effect: p < 0.05) than the education
control group (18%). Interestingly, although CBI is theoretically sup-
posed to alleviate depressive symptoms, this study also reported less
decrease in depressive symptoms in the intervention (20%) than control
group (22%) (time effect: p = 0.008). This is consistent with a study by
Cockayne et al. (2014), that found a significantly higher depression
score in the self-management group than the usual care group
(p = 0.003) after adjusting for baseline scores. This was speculated to
be due to an increase in anxiety and depression after being given dis-
ease-specific information. Suggestively, CBIs has to be designed care-
fully to avoid such counter-intuitive effects. Only one study reported
significant improvement in depressive symptoms (p = 0.005)
(Freedland et al., 2015) while the other studies reported otherwise:
(p = 0.47) (Agren et al., 2012); (p = 0.786) (Cockayne et al., 2014);
(p = 0.403) (Smeulders et al., 2010). This inconsistency could be due to
the recruitment of only depressed patients with a “current major de-
pressive episode” in the former study while the others included patients
without clinical depression, which may have created a ceiling effect.
Two MI studies reported non-statistically significant improvement
in self-care maintenance over 90 days (p = 0.08, Creber et al., 2016)
and 30 days (p = 0.64, Paradis et al., 2010) from enrolment. However,
Creber et al. (2016) reported statistically significant differences
(p = 0.026) between the intervention and control group when adjusted
for several factors including intervention group, sleep apnea, perceived
general health and quality of social support. Others reported statisti-
cally significant improvement in self-care maintenance (p = 0.03), ex-
ercise (p = 0.03) (McCarthy et al., 2016), compliance with sodium re-
striction (p < 0.001), exercise (p < 0.001) and weight monitoring
(p < 0.001) but not medication adherence (p = 0.098) (Otsu &
Moriyama, 2011). However, it may be useful to note that in the study
by Otsu and Moriyama (2011), focus was placed on education and skills
acquisition by elderly and little was mentioned about how MI was
conducted possible due to the word limit. This suggests that MI is ef-
fective in improving HF self-care behaviours especially exercise and
sodium restriction. All the studies speculate that MI improves self-care
through enhanced self-care confidence but only three studies measured
self-care confidence with mixed results (p = 0.31; p = 0.93; p = 0.005)
(Creber et al., 2016; McCarthy et al., 2016; Paradis et al., 2010). As HF
self-care was measured using the same tool, the mixed results warrant
more research on the role of confidence in the mechanism by which MI
influences self-care.
3.2. CBI versus MI: approach in HF self-care research
Two studies described challenging patients' automatic thoughts
(CR) (e.g. exaggerated stress from self-care) and helping them to set
environmental reminders such as placing pill bottles at visible places to
perform certain self-care behaviours (Freedland et al., 2015; Powell
et al., 2010). They preserved the nature of CBT by employing both CR
and BM processes but two other trials seemed only to have incorporated
the CR aspect, focusing on cognitive symptom reinterpretation and
thoughts alteration (Agren et al., 2012; Smeulders et al., 2010). The rest
H.S.J. Chew et al.
lacked detail on how CBI was exemplified, where the remotely relevant
component was the dispelling of cardiac misconceptions, but this could
be too general to indicate whether maladaptive thoughts, feelings or
beliefs were addressed.
All except Otsu and Moriyama (2011) reported the aim of resolving
ambivalence to change. Only McCarthy et al. (2016) described the MI
process according to the MI manual while the rest briefly reported
participants selecting HF self-care behaviours change goals, undergoing
MI and action planning on how to overcome challenges. It is essential to
report the counselling process so that key elements for MI's effective-
ness can be identified, mechanism by which it works to improve self-
care can be elucidated and future interventions can be streamlined.
Only two studies identified key elements of MI that participants ap-
preciated: (1) reflective listening; (2) empathy; (3) individualized pro-
blem solving; and (4) provision of knowledge, skills and resources ac-
tivation (Riegel et al., 2006; Riegel et al., 2017). This would be useful in
future development of HF self-care promotion interventions. However,
generalizability of results is limited due to the nature of a western
qualitative study with a small sample size (N = 15) (Riegel et al., 2006)
(N = 8) (Riegel et al., 2017) (Kukull & Ganguli, 2012). Future studies
may include other objective measures of HF self-care behaviours in-
stead of just measuring the aggregate self-care behaviour score ac-
cording to a validated tool, which may conceal certain significant re-
sults.
It is noteworthy that McCarthy et al. (2016) and Riegel et al. (2006)
reportedly evaluated the effectiveness of MI on ambivalence using
“change talk”, which according to the MI manual, represents one's in-
tention to change (Miller & Rollnick, 2012). Additionally, Paradis et al.
(2010) used the “evALuate the stagEs of chanGe and the cOnviction and
cOnfidence level” (ALEGrO) algorithm to evaluate each patient's con-
fidence, conviction and stage of change according to the transtheore-
tical model. Further studies could contribute by including measurement
of other MI tenets such as motivation to uncover the underlying me-
chanism by which MI improve HF self-care. However, most CBI studies
did not do so except one that measured CBI effect on cognitive change
using the Coping with Symptoms Scale (Smeulders et al., 2010).
3.3. CBI versus MI: intervention structures
3.3.1. Components
All interventions incorporated components of education, goal-set-
ting, action-planning and problem-solving. Common contents of edu-
cation included the definition of HF and the recommended HF self-care
behaviours. Few studies included information on stress management,
relaxation, dealing with emotions, immunization, relationships and
sexual activity. (Agren et al., 2012; Otsu & Moriyama, 2011; Powell
et al., 2010; Smeulders et al., 2009, 2010) Education on coping with
stress especially from the inability to perform self-care and skills on
how to perform constant evaluation of behaviour change may be useful
in sustaining interventional effect on improving self-care behaviours.
Description of the action planning and problem solving processes were
also lacking possibly due to the restriction of word count, making
comparison difficult.
3.3.2. Mode of delivery
CBI ranged from 60 to 150 min/session over 6 to 52 weeks, whereas
studies that used MI ranged from 5 to 60 min/session over 24 weeks.
While two of the studies that used CBI included educational CD or DVD,
none of the MI studies did. Interventions were commonly delivered
individually face-to-face in a heart failure clinic. All studies targeted
solely HF patients but one included a partner living in the same
household as the patient (Agren et al., 2012). Two studies were con-
ducted in groups of 5–10 participants per group to enhance social
support and vicarious learning according to Bandura's self-efficacy
theory (Powell et al., 2010; Smeulders et al., 2010). Three MI studies
and one of the CBI studies conducted home visits, which were
20
Applied Nursing Research 45 (2019) 17–22
speculated to enhance the intervention effectiveness by tailoring self-
care interventions to the patients' living conditions (Creber et al., 2016;
Riegel et al., 2017; Riegel et al., 2006).
3.3.3. Dosage
Studies that used CBI were delivered over a longer period of time as
compared to studies that used MI. CBI programs ranged from 3 to 36
sessions, 60–150 min per session over 6–52 weeks. MI programs ranged
from 1 to 6 sessions, 5–60 min per session over 10 days to 24 weeks. We
were unable to identify an optimal dosage, as there is insufficient evi-
dence on whether CBI independently affected self-care or did so by
mediating depression. Nevertheless, findings suggest that higher dosage
of short intervention sessions instead of a long once-off session may be
more effective in enhancing self-care behaviours. However, increasing
the intervention dosage may increase attrition rates (Creber et al.,
2016; Reigel et al., 2006).
4. Discussion
To our best knowledge, studies that compared the effectiveness
between CBI and MI in a population with HF could not be found and
this paper serves to fill this gap. However, the true causal effect of each
method on HF self-care could not be measured as this study is not a
randomized controlled trial. Nevertheless, findings could inform future
research development in populations with different characteristics such
as comorbid depression.
Overall, MI seemed to be more effective than CBI in improving HF
self-care behaviours especially exercise and sodium restriction. This
could be due to the difference in theoretical underpinning and ap-
proach. CBT was first designed to treat depression, a common co-
morbidity in patients with HF who are 2 to 3 times more likely to de-
velop depression than the general population (Rustad, Stern, Hebert, &
Musselman, 2013). Therefore, it seems intuitive to improve self-care by
alleviating depression, but this discussion showed otherwise.
Both CBT and MI are structured psychological interventions with
user manuals aimed at treating mental health conditions like depression
and substance abuse respectively. Improving HF self-care behaviours is
not a mental health issue and could be as normal as you and I trying to
change a habit. This may explain the limited effect of CBI on improving
HF self-care behaviours, especially when analysing a set of behaviours
together.
Both CBI and MI start by exploring clients' perspectives on certain
maladaptive behaviours, which in this case are inadequate HF self-care
behaviours. While CBI focuses on the therapist identifying and chal-
lenging clients' irrational thoughts, MI focuses on the therapist's com-
munication style that allows clients to hear their own ambivalence and
challenge their own maladaptive thoughts. While CBI facilitates re-
interpretation and replacement of thoughts, MI promotes the opposite
by “rolling with resistance”. While CBI studies focused on restructuring
thoughts and modifying behaviours by enacting environmental cues, MI
studies focused on helping patients to recognize and resolve their own
ambivalence through communication techniques – expressing empathy;
reflective listening; developing discrepancy and supporting self-effi-
cacy. This suggests that behaviour change may be more significant
when clients themselves recognize their own ambivalence to change,
identify the reasons to change and actively develop personalised action
plans rather than the therapist doing it for them. Therefore, MI may be
more applicable in promoting HF self-care especially when there is no
irrational thoughts but rather maladaptive ones, where clients have yet
to adapt to the self-care behaviours needed to cope with their diagnosis.
While CBI extends the talk therapy by setting up environmental cues
to facilitate behavioural modifications, MI ends. This is coherent with
the nature of MI as a prelude to education and skills training programs
to increase the motivation to continue with the intended treatment
(Westra & Dozois, 2006). Setting environmental reminders to take
medications may be effective only if forgetfulness is the reason for
H.S.J. Chew et al.
medication non-compliances. Taking medications is comparatively
more convenient than going to the park to jog for 30 min and this may
require more than an environmental cue to comply. This may explain
why MI seems more effective in improving self-care behaviours by
enhancing motivation rather than through setting environmental re-
minders, which would not be effective if one does not want to change in
the first place. Nevertheless, our findings indicated that CBI might be
effective in improving medication adherence through environmental
modifications.
Employing MI as a prelude to CBI has been speculated to enhance
response and decrease attrition from the therapy but more research is
needed to establish its effectiveness especially in HF patients (Westra &
Dozois, 2006). To the authors' knowledge, there are currently no studies
exploring the use of such combined therapy on improving HF self-care.
Further studies are needed to uncover the optimal intervention dosage
and delivery to sustain significant changes.
The attrition rate for studies that used MI was higher than that of
CBI, ranging from 16.6% to 49% versus 3.2% to 27.3%. Consideration
of the paradoxically high rate of attrition in the MI studies poses
scepticism regarding the essential motivational aspect of the interven-
tion since the included participants should already be motivated to
change since they agreed to participant in the studies (Creber et al.,
2016, McCarthy et al., 2016). Moreover, CBI studies were generally
conducted over a longer period of time, which should increase the at-
trition rate. Common reasons for attrition were consistent throughout
MI and CBI studies - lost to follow-up, decline and discontinuation due
to medical conditions and death. It may be useful for future studies to
report details of the intervention process for readers to evaluate effec-
tive components.
In addition, most studies were heavily reliant on self-reports, risking
respondent bias such as recall and social desirability bias that under-
mines the accuracy of results (Krumpal, 2013). It is noteworthy that
Creber et al. (2016) tried to minimize response bias by comparing re-
sponses of those participants who have completed the program and
those lost to follow-up (Fisher & Katz, 2008). Intervention validity was
strengthened in three studies that assessed for difficulty in performing
at least one SCB before recruitment (Creber et al., 2016; Riegel et al.,
2017; Paradis et al., 2010). However, a 34% refusal rate in one study
and another that excluded patients who expressed unwillingness to
change their SCB may indicate a higher willingness to change in the
included participants, which may have augmented results (Creber et al.,
2016; Powell et al., 2010). Although randomization was conducted in
the latter study, it was done after recruitment, which would have pre-
cluded most patients who are resistant to change. Therefore, assessment
of self-care difficulty should have been done after random assignment
of subjects to enhance the generalizability of the results. Also, results
could have been limited by a ceiling effect on how much self-care be-
haviours can improve over time especially in samples with higher so-
cioeconomic status, access to resources (Chen & Miller, 2013), ad-
vanced stages of HF, and proficiency in optimal self-care (Creber et al.,
2016). The high willingness to change and ceiling effect defeats the
purpose of conducting the interventions aimed at enhancing willingness
to change.
5. Recommendations
As suggested by various theoretical frameworks such as the Theory
of Reasoned Action (Sheppard, Hartwick & Warshaw, 1988) and Theory
of Planned Behaviours (Armitage & Conner, 2001), a behaviour per-
formance is based on the intention-behaviour link. A better under-
standing of this mechanism in patients with HF could shed light on the
initiation and sustainability of self-care behaviour changes. Future re-
search could measure intention to change in addition to behavioural
change and follow-up for longer periods to evaluate the sustainability of
the interventions. From this discussion, MI seems to be effective in
enhancing clients' motivation/intention to change while practical skills
21
Applied Nursing Research 45 (2019) 17–22
taught during CBI could enhance the translation of intention to beha-
viour change, strengthening the initiation and sustainability self-care.
In addition, it may be noteworthy to consider the cultural uniqueness of
the population receiving MI and CBI due to different priorities and
social practice norms (Dickson, McCarthy, Howe, Schipper, & Katz,
2013).
6. Conclusion
This paper discussed the suitability of CBI and MI on improving self-
care in patients with HF in terms of theoretical underpinning, approach
and effectiveness. While CBI may be useful in improving self-care be-
haviours such as medication adherence due to forgetfulness, MI shows
more potential in improving exercise and sodium restriction. Future
trials could consider measuring self-care behaviours individually to
ascertain interventional effectiveness as different behaviours may re-
quire different intentions such as inhibitory self-control for sodium
restriction and motivation to exercise. Key effective components of CBI
was suggested to be setting environmental cues, enhancing knowledge
and skills training while that of MI is the style of communication that
evokes ambivalence and change talk. The brief nature of MI compared
with the comprehensive nature of CBI suggests a possible synergistic
effect of a combined therapy for further research. Future studies should
develop methods to include patients unwilling to change, the true
target population of these counselling methods despite the various
constraints in doing so. Future studies should also at least report and
measure the basic tenets of CBI and MI included in their interventions.
This would serve to facilitate insightful understanding of the me-
chanism by which each element works in enhancing self-care in pa-
tients with HF streamline cost- and outcome-effective interventions.
Conflict of interest
No conflict of interest has been declared by the author(s).
Funding statement
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
References
Agren, S., Evangelista, L. S., Hjelm, C., & Strömberg, A. (2012). Dyads affected by chronic
heart failure: A randomized study evaluating effects of education and psychosocial
support to patients with heart failure and their partners. Journal of Cardiac Failure,
18(5), 359–366.
Apodaca, T. R., & Longabaugh, R. (2009). Mechanisms of change in motivational inter-
viewing: A review and preliminary evaluation of the evidence. Addiction, 104(5),
705–715.
Armitage, C. J., & Conner, M. (2001). Efficacy of the theory of planned behaviour: A
meta‐analytic review. British Journal of Social Psychology, 40(4), 471–499.
Aromataris, & Riitano (2014). Constructing a search strategy and searching for evidence:
A guide to the literature search for a systematic review. American Journal of Nursing,
114(5), 49–56.
Barnason, S., Zimmerman, L., & Young, L. (2012). An integrative review of interventions
promoting self‐care of patients with heart failure. Journal of Clinical Nursing, 21(3‐4),
448–475.
Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S. W., Moring, J., O'Brien, R., ...
McGovern, J. (2001). Randomized controlled trial of motivational interviewing,
cognitive behavior therapy, and family intervention for patients with comorbid
schizophrenia and substance use disorders. American Journal of Psychiatry, 158(10),
1706–1713.
Bryant, R. A., Moulds, M. L., Guthrie, R. M., et al. (2008). A randomized controlled trial of
exposure therapy and cognitive restructuring for posttraumatic stress disorder.
Journal of Consulting and Clinical Psychology, 76(4), 695.
Chen, E., & Miller, G. E. (2013). Socioeconomic status and health: Mediating and mod-
erating factors. Annual Review of Clinical Psychology, 9, 723–749.
Chen, A. M., Yehle, K. S., Albert, N. M., Ferraro, K. F., Mason, H. L., Murawski, M. M., &
Plake, K. S. (2014). Relationships between health literacy and heart failure knowl-
edge, self-efficacy, and self-care adherence. Research in Social and Administrative
Pharmacy, 10(2), 378–386.
Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R.
J., ... Turner, J. A. (2016). Effect of mindfulness-based stress reduction vs cognitive
H.S.J. Chew et al.
behavioral therapy or usual care on back pain and functional limitations in adults
with chronic low back pain: A randomized clinical trial. JAMA, 315(12), 1240–1249.
Chew, H. S. J., & Lopez, V. (2017). Empowered to self-care: A photovoice study in patients
with heart failure. Journal of Transcultural Nursing, 29(5), 410–419.
Cockayne, S., Pattenden, J., Worthy, G., Richardson, G., & Lewin, R. (2014). Nurse fa-
cilitated self-management support for people with heart failure and their family
carers (SEMAPHFOR): A randomised controlled trial. International Journal of Nursing
Studies, 51(9), 1207–1213.
Cook, C., Cole, G., Asaria, P., Jabbour, R., & Francis, D. P. (2014). The annual global
economic burden of heart failure. International Journal of Cardiology, 171(3),
368–376.
Creber, R. M., Patey, M., Lee, C. S., et al. (2016). Motivational interviewing to improve
self-care for patients with chronic heart failure: MITI-HF randomized controlled trial.
Patient Education and Counseling, 99(2), 256–264.
Crundall-Goode, A., Goode, K. M., & Clark, A. L. (2016). What impacts do anxiety, de-
pression, perceived control and technology capability have on whether patients with
chronic heart failure take-up or continue to use home tele-monitoring services? Study
design of ADaPT-HF. European Journal of Cardiovascular Nursing, 1–7 (doi:
1474515116657465).
Dickson, V. V., McCarthy, M. M., Howe, A., Schipper, J., & Katz, S. M. (2013).
Sociocultural influences on heart failure self-care among an ethnic minority black
population. Journal of Cardiovascular Nursing, 28(2), 111–118.
Dickson, V. V., Melkus, G. D. E., Katz, S., et al. (2014). Building skill in heart failure self-
care among community dwelling older adults: Results of a pilot study. Patient
Education and Counseling, 96(2), 188–196. https://doi.org/10.1016/j.pec.2014.04.
018.
Fairburn, C. G., Bailey-Straebler, S., Basden, S., Doll, H. A., Jones, R., Murphy, R., ...
Cooper, Z. (2015). A transdiagnostic comparison of enhanced cognitive behaviour
therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating dis-
orders. Behaviour Research and Therapy, 70, 64–71.
Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J., ...
Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for
persons with heart failure: a systematic review and meta-analysis. Annals of Internal
Medicine, 160(11), 774–784.
Fisher, R., & Katz, J. E. (2008). Social-desirability bias and the validity of self-reported
values. Social desirability bias and the validity of self-reported values. Psychology and
Marketing, 17(February), 105–120.
Freedland, K. E., Carney, R. M., Rich, M. W., Steinmeyer, B. C., & Rubin, E. H. (2015).
Cognitive behavior therapy for depression and self-care in heart failure patients: A
randomized clinical trial. Journal of American Medical Association Internal Medicine,
175(11), 1773–1782.
Hyland, P., & Boduszek, D. (2012). Resolving a difference between cognitive therapy and
rational emotive behaviour therapy: Towards the development of an integrated CBT
model of psychopathology. Mental Health Review Journal, 17(2), 104–116.
Joanna Briggs Institute (2016). The Joanna Briggs Institute Critical Appraisal tools for use in
JBI systematic reviews. Checklist for qualitative researchAustrialia: The Joanna Briggs
Institute.
Karyotaki, E., Riper, H., Twisk, J., Hoogendoorn, A., Kleiboer, A., Mira, A., ... Andersson,
G. (2017). Efficacy of self-guided internet-based cognitive behavioral therapy in the
treatment of depressive symptoms: A meta-analysis of individual participant data.
JAMA Psychiatry, 74(4), 351–359.
Klompstra, L., Jaarsma, T., & Strömberg, A. (2015). Physical activity in patients with
heart failure: Barriers and motivations with special focus on sex differences. Patient
Preference and Adherence, 9, 1603–1610.
Krumpal, I. (2013). Determinants of social desirability bias in sensitive surveys: A lit-
erature review. Quality and Quantity, 47(4), 2025–2047.
Kukull, W. A., & Ganguli, M. (2012). Generalizability: the trees, the forest, and the low-
hanging fruit. Neurology, 78(23), 1886–1891.
Lundahl, B., Moleni, T., Burke, B. L., et al. (2013). Motivational interviewing in medical
care settings: A systematic review and meta-analysis of randomized controlled trials.
Patient Education and Counseling, 93(2), 157–168.
Lundgren, J., Andersson, G., & Johansson, P. (2015). Can cognitive behaviour therapy be
beneficial for heart failure patients? Current Heart Failure Reports, 12(2), 166–172.
Mahoney, J. S. (2001). An ethnographic approach to understanding the illness experi-
ences of patients with congestive heart failure and their family members. Heart &
Lung: The Journal of Acute and Critical Care, 30(6), 429–436.
Martins, R. K., & McNeil, D. W. (2009). Review of motivational interviewing in promoting
health behaviors. Clinical Psychology Review, 29(4), 283–293.
McCarthy, M. M., Dickson, V. V., Katz, S. D., & Chyun, D. A. (2016). An exercise coun-
seling intervention in minority adults with heart failure. Rehabilitation Nursing, 1–13.
Miller, W. R., & Rollnick, S. (2004). Talking oneself into change: Motivational inter-
viewing, stages of change, and therapeutic process. Journal of Cognitive Psychotherapy,
18(4), 299–308.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. New
York: Guilford press.
22
Applied Nursing Research 45 (2019) 17–22
Moser, D. K., Dickson, V., Jaarsma, T., Lee, C., Stromberg, A., & Riegel, B. (2012). Role of
self-care in the patient with heart failure. Current Cardiology Reports, 14(3), 265–275.
Olatunji, B. O., Kauffman, B. Y., Meltzer, S., Davis, M. L., Smits, J. A., & Powers, M. B.
(2014). Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-
analysis of treatment outcome and moderators. Behaviour Research and Therapy, 58,
65–74.
Oosterom-Calo, R., Van Ballegooijen, A. J., Terwee, C. B., et al. (2012). Determinants of
heart failure self-care: A systematic literature review. Heart Failure Reviews, 17(3),
367–385.
Otsu, H., & Moriyama, M. (2011). Effectiveness of an educational self-management pro-
gram for outpatients with chronic heart failure. Japan Journal of Nursing Science, 8(2),
140–152.
Paradis, V., Cossette, S., Frasure-Smith, N., et al. (2010). The efficacy of a motivational
nursing intervention based on the stages of change on self-care in heart failure pa-
tients. The Journal of Cardiovascular Nursing, 25(2), 130–141.
Peters-Klimm, F., Freund, T., Kunz, C. U., et al. (2013). Determinants of heart failure self-
care behaviour in community-based patients: A cross-sectional study. European
Journal of Cardiovascular Nursing, 12(2), 167–176.
Pladevall, M., Divine, G., Wells, K. E., Resnicow, K., & Williams, L. K. (2015). A rando-
mized controlled trial to provide adherence information and motivational inter-
viewing to improve diabetes and lipid control. The Diabetes Educator, 41(1), 136–146.
Powell, L. H., Calvin, J. E. J., Richardson, D., et al. (2010). Self-management counseling
in patients with heart failure: The heart failure adherence and retention randomized
behavioral trial. Journal of the American Medical Association, 304(12), 1331–1338.
Reyes, E. B., Ha, J. W., Firdaus, I., Ghazi, A. M., Phrommintikul, A., Sim, D., ... Cowie, M.
R. (2016). Heart failure across Asia: Same healthcare burden but differences in or-
ganization of care. International Journal of Cardiology, 223, 163–167.
Riegel, B., Dickson, V. V., Garcia, L. E., Masterson Creber, R., & Streur, M. (2017).
Mechanisms of change in self-care in adults with heart failure receiving a tailored,
motivational interviewing intervention. Patient Education and Counseling, 100(2),
283–288.
Riegel, B., Dickson, V. V., Hoke, L., McMahon, J. P., Reis, B. F., & Sayers, S. A. (2006).
Motivational counseling approach to improving heart failure self-care: Mechanisms
of effectiveness. The Journal of Cardiovascular Nursing, 21(3), 232–241.
Riegel, B., Lee, C. S., Dickson, V. V., & Carlson, B. (2009). An update on the self-care of
heart failure index. The Journal of Cardiovascular Nursing, 24(6), 485–497.
Riper, H., Andersson, G., Hunter, S. B., de Wit, J., Berking, M., & Cuijpers, P. (2014).
Treatment of comorbid alcohol use disorders and depression with cognitive‐beha-
vioural therapy and motivational interviewing: A meta‐analysis. Addiction, 109(3),
394–406.
Rustad, J. K., Stern, T. A., Hebert, K. A., & Musselman, D. L. (2013). Diagnosis and
treatment of depression in patients with congestive heart failure: A review of the
literature. The Primary Care Companion for CNS Disorders, 15(4), e1–e13.
Satre, D. D., Leibowitz, A., Sterling, S. A., Lu, Y., Travis, A., & Weisner, C. (2016). A
randomized clinical trial of Motivational Interviewing to reduce alcohol and drug use
among patients with depression. Journal of Consulting and Clinical Psychology, 84(7),
571–579.
Shearer, N. B., Fleury, J., Ward, K. A., & O'Brien, A. M. (2012). Empowerment inter-
ventions for older adults. Western Journal of Nursing Research, 34(1), 24–51.
Sheppard, B. H., Hartwick, J., & Warshaw, P. R. (1988). The theory of reasoned action: A
meta-analysis of past research with recommendations for modifications and future
research. Journal of Consumer Research, 15(3), 325–343..
Smeulders, E. S. T. F., van Haastregt, J. C. M., Ambergen, T., et al. (2009). The impact of a
self-management group programme on health behaviour and healthcare utilization
among congestive heart failure patients. European Journal of Heart Failure, 11(6),
609–616.
Smeulders, E. S. T. F., van Haastregt, J. C. M., Ambergen, T., et al. (2010). Nurse-led self-
management group programme for patients with congestive heart failure:
Randomized controlled trial. Journal of Advanced Nursing, 66(7), 1487–1499.
Spohr, S. A., Taxman, F. S., Rodriguez, M., & Walters, S. T. (2016). Motivational inter-
viewing fidelity in a community corrections setting: Treatment initiation and sub-
sequent drug use. Journal of Substance Abuse Treatment, 65, 20–25.
Syzdek, M. R., Green, J. D., Lindgren, B. R., & Addis, M. E. (2016). Pilot trial of gender-
based motivational interviewing for increasing mental health service use in college
men. Psychotherapy, 53(1), 124–129.
Tung, Y. C., Chou, S. H., Liu, K. L., Hsieh, I. C., Wu, L. S., Lin, C. P., ... Chu, P. H. (2016).
Worse prognosis in heart failure patients with 30-day readmission. Acta Cardiologica
Sinica, 32(6), 698.
Westra, H. A., & Dozois, D. J. (2006). Preparing clients for cognitive behavioral therapy: A
randomized pilot study of motivational interviewing for anxiety. Cognitive Therapy
and Research, 30(4), 481–498.
Yehle, K. S., & Plake, K. S. (2010). Self-efficacy and educational interventions in heart
failure: a review of the literature. Journal of Cardiovascular Nursing, 25(3), 175–188.
Ziaeian, B., & Fonarow, G. C. (2016). The prevention of hospital readmissions in heart
failure. Progress in Cardiovascular Diseases, 58(4), 379–385.